Livingston Amateur Radio Klub
P.O. Box 283
Howell, MI 48844
MEMBERSHIP APPLICATION

CALL: ____________ FIRST NAME: __________________ LAST NAME: ________________________

ADDRESS: _____________________ CITY: __________________ STATE: _______ ZIP: ____________

PHONE #: ______________ CELL PHONE (OPTIONAL) ______________ E-MAIL: _______________

LICENSE CLASS: ______________ EXPIRATION DATE: _____________ BIRTHDAY: ___/___/XXXX

ARRL MEMBER: Y____ N _____ ARES: Y _____ N ______ RACES: Y_____ N _____

********IF YOU DO NOT WANT THIS INFO PUBLISHED INITIAL HERE: ________*****

FAMILY MEMBERS APPLYING:

NAME: ___________________________________________ CALL: _________________

RELATIONSHIP: ________________ LICENSE CLASS: ______________

BIRTHDAY: ___/___/XXXX E-MAIL: _______________

ARRL MEMBER: Y____ N _____ ARES: Y _____ N ______ RACES: Y_____ N _____
 

NAME: ___________________________________________ CALL: _________________

RELATIONSHIP: ________________LICENSE CLASS: ______________

BIRTHDAY: ___/___/XXXX E-MAIL: _______________

ARRL MEMBER: Y____ N _____ ARES: Y _____ N ______ RACES: Y_____ N _____
 

NAME: ___________________________________________ CALL: _________________

RELATIONSHIP: ________________LICENSE CLASS: ______________ BIRTHDAY: ___/___/XXXX

ARRL MEMBER: Y____ N _____ ARES: Y _____ N ______ RACES: Y_____ N _____
MEMBERSHIP DUES: $ 20.00 PER YEAR (JAN 1 – DEC 31) FIRST MEMBER $5.00 EACH ADDITIONAL MEMBER.
TOTAL PAID: $ ____________________